Bishop's Cleeve Care Home

People and relatives consistently said they felt safe. Inspectors also saw staff respond promptly to meals and support needs.

“People and relatives told us they felt people were safe and that the care provided was good.” from the report

Inspectors found the home clean and without unpleasant smells. People and relatives also praised the cleanliness of rooms and the environment.

“We observed the home to be clean and there were no malodours.” from the report

The required checks were completed before new staff started work, including criminal record checks.

“Staff were recruited safely. All required checks were made before new staff began working at the home.” from the report

People were supported to access GPs, dentists, opticians, chiropody and other health professionals. Visiting healthcare professionals gave positive feedback.

“Records showed people were supported to access support from healthcare professionals such as speech and language therapists, occupational therapists and physiotherapists.” from the report

The interim manager had identified shortfalls and started actions, including reviewing incidents, improving communication and making missing legal referrals.

“The interim manager had taken immediate action to improve communication and governance processes.” from the report

Risk assessments and reviews for eating and drinking, mobility, falls and moving and handling were not always robust. Staff did not always have clear guidance on how to keep people safe.

“People's risks were not always robustly assessed and reviewed.” from the report

Medicine patches, 'when required' medicines, expiry dates and a cream not listed on the medicine record were not always managed safely. One person's medicines were given in a way that did not follow their plan.

“Medicines are not always managed safely for people living at the service.” from the report

Ten of 19 people identified as needing legal referrals had not been referred until inspectors asked about this. Some mental capacity records were also incomplete or not decision-specific.

“This placed people at risk of unlawful deprivation of their liberty.” from the report

People were not always involved in their care or supported to make choices. Inspectors saw limited meaningful engagement, including periods of up to 45 minutes for some people living with dementia.

“We observed people living with dementia going for periods of time, sometimes 45 minutes, without any meaningful engagement from staff.” from the report

Audits had not been carried out routinely since August 2023. There were no effective audits for medicines, clinical governance or care plans, and there was no clear service improvement plan.

“There were no audit processes in relation to the management of medicines, clinical governance and care plan audits.” from the report

Systems did not ensure fire and legionella checks continued when the responsible person was absent. Hazardous substances were accessible, and infection control audits were not being completed.

“The service had not implemented a system to ensure fire and legionella safety checks were being carried out in the absence of the person responsible for completing these.” from the report